Issues Our effort Our vision Digital Healthcare Services for Cognitive ...

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Increased computer illiteracy among Greek older adults: Despite the widespread ... the provision of cognitive assessment and cognitive rehabilitation services.
Stelios Zygouris, MSc

Digital Healthcare Services for Cognitive Impairment: the Vision of the Greek Association of Alzheimer’s Disease and Related Disorders (GAADRD)

Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece

Magdalini Tsolaki, MD, PhD Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece Greek Association of Alzheimer’s Disease and Relative Disorders, Thessaloniki, Greece

Stelios Zygouris, MSc / Magdalini Tsolaki, MD, PhD

Information and Communication Technology (ICT) and its application in the field of cognitive impairment has received considerable research and commercial interest. At the same time the cost-effectiveness of ICT applications and the proper way of ICT implementation in healthcare have been the source of heated debate. Eager to embrace the potential of ICT in a country plagued by financial and organizational issues the GAADRD has embarked on an effort to overcome issues commonly associated with ICT implementation through research, innovation and social impact actions with the ultimate aim of achieving its vision of freely available digital healthcare services for all Greek older adults.

Corresponding author Stelios Zygouris E-mail: [email protected]

Fig. 1 Complete Brain Workout software.

Related publications by members of the GAADRD Zygouris S., Tsolaki M., Chapter “New Technologies and Neuropsychological Evaluation of Older Adults: Issues and Challenges” in “Handbook of Research on Innovations in the Diagnosis and Treatment of Dementia”, Published by: IGI Global.

Fig. 2 Patients in a computerized CT program at a GAADRD day center.

Issues

• Increased computer illiteracy among Greek older adults: Despite the widespread use of computers and the internet by Greek adults, people over 60 years old often lack computer skills and are therefore unable to actively participate in today’s digital society. • Lack of computerized cognitive assessment and cognitive training tools designed for Greek older adults: Currently few computerized instruments are used in cognitive healthcare facilities in Greece and these are not designed for Greek older adults. Usually they are translations of internationally available instruments. • Limited access to cognitive evaluation and cognitive rehabilitation for older adults living in remote areas: The topography of Greece often hinders the provision of cognitive assessment and cognitive rehabilitation services. Remote areas and small islands lack the necessary infrastructure and specialized personnel for addressing the needs of people with cognitive disorders. At the same time the burden of caring for a patient with cognitive disorder leaves caregivers unable to visit healthcare services and receive valuable support. • High cost of commercially available computerized instruments: The majority of available computerized instruments are owned by private companies and costs related to use and ownership hinder their integration in public health services. Only a small number of public health services have access to computerized instruments.

Our effort

• Introducing older adults to new technologies: The GAADRD runs regular seminars introducing computers and new technologies to older adults. Currently older adults can enroll to seminars teaching basic computer skills or to a cognitive training program utilizing computerized exercises presented in computers with touch screens which allow even computer illiterate people to participate. Results are encouraging as older adults exhibit a positive attitude towards new technologies. They report that they enjoy learning new things and believe that computer knowledge will help them communicate better with their children and grandchildren who are computer savvy. At the same time research validation of the effectiveness of computerized cognitive training at GAADRD day centers supports its continued use. • Digital caregiver support: The GAADRD has implemented online support groups for caregivers. These groups utilize freely available teleconference technologies such as Skype and are coordinated by a trained psychologist. A study conducted by the GAADRD has shown that they are equally effective to in-person support groups. • Design of computerized instruments for Greek older adults: Under the auspices of the “Εν-ΝΟΗΣΗΣ” project for the diagnosis, treatment and support of patients with cognitive disorders we have created computerized instruments specifically designed for Greek older adults. We have created 5 Virtual Reality (VR) cognitive training game-based exercises modeled after everyday activities (VR supermarket, VR garden, VR laundry, VR kitchen, VR bookcase) and the first computerized cognitive assessment battery for Greek older adults. The VR super market (VSM) has also been validated as the only VR application that can be used as a screening test for mild cognitive impairment (MCI) with a sensitivity of 82,35% and a specificity of 95,24%. A study evaluating VSM’s potential for remote cognitive screening without the need for an examiner indicates that it can be even more sensitive in detecting MCI if longitudinal performance data are used. The study is still in progress and results will be published soon. In addition to our VR instruments we have also created a suite with 1000 verbal exercises for cognitive training specifically designed for Greek older adults. This suite is currently being used and evaluated in the day centers of the GAADRD. • Availability and scalability of computerized instruments designed by the GAADRD: We have designed computerized instruments that can be easily distributed and used by all health services, patients and caregivers who have a standard PC. All instruments have web-based versions while the VR applications also have Windows and Android versions for offline use on PCs and tablet PCs. We have avoided the use of specialized equipment in order to ensure wider compatibility. Despite our emphasis on low-cost solutions we have also trialed more advanced systems such as smart homes in order to be ready to implement them when technological progress will allow for their low-cost, large scale implementation. • Removing barriers associated with cost: We believe that cost should not be a barrier to healthcare access therefore we are freely distributing our applications to public healthcare services while many versions of these application are freely available online for patients and caregivers to use on their own.

Our vision

• A wide range of computerized instruments covering all aspects of cognitive assessment and rehabilitation / training: The applications we have already created will form the basis for a suite of computerized instruments available to healthcare personnel, patients and caregivers. We are in the process of implementing a process of redesign and usability improvement of all our applications in collaboration with designers specialized in usability testing and design for older adults. • Remote cognitive screening for all older adults: By creating instruments that can be used by healthcare personnel with minimal training and pioneering the use of VR technology for remote cognitive screening we aim to make cognitive screening accessible to everyone. We want to enable people with limited access to healthcare facilities and services to screen their memory regularly. Our aim is to be able to detect possible cognitive impairment at the MCI stage thus allowing for more efficient intervention. • Integration: We are taking steps to digitize our patient database and our next step is the integration of all data including data from the computerized instruments we have created. Currently we are leading an effort for the harmonization and integration of all data from cognitive health services in Greece in a unified database.

Zygouris S., Giakoumis D., Votis K., Doumpoulakis S., Ntovas K., Segkouli S., Karagiannidis C.,Tzovaras D., Tsolaki M., “Can a virtual reality cognitive training application fulfill a dual role? Using the Virtual Super Market cognitive training application as a screening tool for mild cognitive impairment”, Journal of Alzheimer’s Disease. 2015 Jan 1;44(4):1333-47. doi: 10.3233/JAD-141260 Zygouris S., Tsolaki M., “Computerized Cognitive Testing for Older Adults – A review”, American Journal of Alzheimer’s Disease and Other Dementias. 2015 Feb;30(1):13-28. doi: 10.1177/1533317514522852 Chaldogeridis Α., Tsiatsos T., Gialaouzidis M., Tsolaki M., “Comparing data from a computer based intervention program for patients with Alzheimer’s disease”, 29th Alzheimer Disease Conference, San Juan, Puerto Rico, 1 – 4 May, 2014. HCII 2014. Apostolidis I., Karakostas A., Dimitriou T., Tsiatsos T., Tsolaki M., “Advanced Bio-feedback and Collaborative Techniques to Support Caregivers of Alzheimer Patients”, 6th International Conference on Intelligent Networking and Collaborative Systems (INCoS – 2014) Salerno, Italy, September 10 – 12, 2014.

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Fig. 3 Screenshot of the Virtual Supermarket application (English version).